Inspection Reports for
Navigate MC at Featherstone at Hickory Trail
2450 Hickory Trail, Iowa City, IA, 52245
Back to Facility Profile5 Reports
Inspection Report — Feb 9, 2026
Renewal
Date: Feb 9, 2026
Visit Reason
Scheduled recertification visit to determine compliance with certification of an Assisted Living Program for People with Dementia. The visit also investigated Incident #130721-I, Incident #131205-I, Incident #131198-M, and Complaint #131195-A.
Complaint Details
Incident #130721-I, Incident #131205-I, Incident #131198-M, Complaint #131195-A were investigated during the visit.
Findings
No regulatory insufficiencies were cited during the investigations of Incident #130721-I and Incident #131205-I. One regulatory insufficiency was cited related to medication administration errors during the investigations of Incident #131198-M and Complaint #131195-A.
Violations (1)
481-67.5(2)f(4) Medications: The program failed to administer medications as prescribed by the tenant's physician for 2 of 3 tenants reviewed. Tenant #1 received Methotrexate Sodium daily instead of weekly, resulting in hospitalization for Methotrexate toxicity. Tenant #2 received Aspercreme three times daily instead of as needed.
Inspection Report — Jan 14, 2026
Enforcement
Date: Jan 14, 2026
Visit Reason
This citation was issued following investigations #130721-I, #131205-I, #131195-A, and #131198-M conducted from January 14, 2026 to February 9, 2026 regarding medication administration errors at Navigate Memory Care at Featherstone.
Findings
The program failed to administer medications as prescribed to two tenants. Tenant #1 received Methotrexate Sodium daily instead of weekly, resulting in hospitalization for Methotrexate toxicity. Tenant #2 received Aspercreme three times daily instead of as needed.
Violations (2)
481-67.5(2)f(4) Medications: The program failed to administer Methotrexate Sodium as prescribed to Tenant #1, giving it daily instead of weekly, which caused toxicity and hospitalization. The Licensed Practical Nurse overrode warnings and ignored pharmacy inquiries about the dosing schedule.
481-67.5(2)f(4) Medications: Tenant #2 received Aspercreme three times daily instead of as needed, and the program confirmed the medication was not administered as prescribed.
Report Facts
Fine amount: 6000
Inspection Report — Jun 11, 2025
Follow-Up
Date: Jun 11, 2025
Visit Reason
This revisit was conducted to determine progress made in correcting violations cited during the initial certification completed on 2025-03-25.
Findings
The program failed to complete thorough evaluations of tenants' health, cognitive, and functional status prior to occupancy and annually or with significant change for multiple tenants. The program also failed to ensure staff checked on a tenant as indicated in her service plan, with supervision checks documented inaccurately and not conducted as required.
Violations (3)
481-69.22(1) Evaluation prior to occupancy: The program failed to complete a thorough health evaluation prior to occupancy for Tenant #4 admitted within the previous month. The Iowa Assisted Living Assessment did not thoroughly evaluate her health status.
481-69.22(3) Evaluation annually and with significant change: The program failed to evaluate the health, cognitive, and functional needs of Tenants #2, #6, and #7 when they experienced significant changes in condition, updating service plans without proper re-evaluation.
481-69.29(4) Staffing: The program failed to ensure staff checked on Tenant #5 as indicated in her service plan. Supervision checks were not completed prior to 2025-05-29 and documentation showed multiple checks recorded at the same time, indicating inaccurate monitoring.
Inspection Report — Mar 25, 2025
Renewal
Date: Mar 25, 2025
Visit Reason
The visit was an initial certification visit to determine compliance with certification of an Assisted Living Program for People with Dementia. The investigation included complaints #127296-C, #126864-C, and #126558-C.
Complaint Details
Complaints #127296-C, #126864-C, and #126558-C were investigated during the visit.
Findings
Multiple regulatory insufficiencies were cited related to program policies and procedures, incident reporting, tenant rights, medication administration, tenant evaluations, criteria for admission and retention, and service plans. The facility failed to complete required incident reports, provide adequate care and supervision, administer medications as ordered, complete thorough tenant evaluations, and update service plans appropriately.
Violations (9)
481-67.2(1)e Program Policies and Procedures: The program's incident report policy did not contain all required information and failed to ensure all accidents or unusual occurrences affecting tenants were reported as incidents.
481-67.2(3) Program Policies and Procedures: The facility failed to ensure incident reports were completed for a tenant with wounds of unknown origin and staff failed to write incident reports as required.
481-67.3(2) Tenant Rights: The program failed to provide adequate care and services to two tenants, including failure to provide supervision and respond appropriately to falls and injuries.
481-67.5(2)f(4) Medications: The program failed to administer medications according to physician orders for two tenants during medication passes.
481-69.22(1) Evaluation of Tenant: The program failed to complete thorough health evaluations prior to occupancy for two tenants admitted in the past three months.
481-69.22(2) Evaluation of Tenant: The program failed to complete thorough health evaluations within 30 days of occupancy for two tenants admitted in the past three months.
481-69.23(1)c(1) Criteria for Admission / Retention of Tenants: The program retained two tenants who displayed physical aggression and failed to intervene appropriately.
481-69.26(3) Service Plans: The program failed to update service plans for four tenants with significant changes in condition.
481-69.26(4)e Service Plans: The program failed to identify nursing facility care preferences on service plans for three tenants.
Inspection Report — Mar 17, 2025
Enforcement
Date: Mar 17, 2025
Visit Reason
Initial certification survey conducted from 3/17/25 to 3/25/25 with a complaint identified as 127296-C.
Complaint Details
Complaint #127296-C
Findings
The program failed to provide adequate care and services to two tenants, Tenant #1 and Tenant #7, resulting in multiple falls and inadequate supervision. The Executive Director confirmed the program did not meet tenant needs.
Violations (2)
481-67.3(2) Tenant rights: The program failed to provide adequate care and services to Tenant #7, who experienced multiple falls between 1/28/25 and 3/19/25 without adequate supervision or clear staff direction on safety checks.
481-67.3(2) Tenant rights: The program failed to provide adequate care and services to Tenant #1, who experienced multiple falls and elevated heart rates without timely nursing intervention or clear supervision instructions.
Report Facts
Fine amount: 2500
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